Music and dance in chronic lung disease

Music listening

Listening to music has the same potential benefits for people with chronic lung disease as those without, such as improving mood and relaxation. However, there are also a variety of potential impacts specifically relating to the management of their disease.

It is well established that physical activity and exercise are core components of living well in chronic lung disease; however, symptoms such as dyspnoea, fatigue and anxiety can inhibit participation. One area that has received attention is the use of music listening as an adjunct to exercise. In healthy people, listening to music during exercise has been shown to improve work output and reduce perceived exertion, with further positive effects on mood and enjoyment [9].

A recent systematic review explored the use of music as a distractive auditory stimulus in chronic obstructive pulmonary disease (COPD) [10]. The authors considered distractive auditory stimuli in relation to exercise capacity, symptoms and health-related quality of life during exercise training and testing, and for symptom management at rest. They found that distractive auditory stimuli improved exercise capacity and health-related quality of life when combined with exercise training over time. Dyspnoea was lessened during exercise training, but results were inconsistent during short-term exercise testing and for symptom management at rest. Subsequent research has shown that music listening during a high-intensity endurance test can reduce dyspnoea and increase endurance time [11], and can reduce dyspnoea during low-intensity exercise in elderly subjects with COPD [12]. Similarly, rhythmic auditory stimulation, in which music is linked with movement to elicit a neurological response and affect behaviour, has been shown to increase 6-min walk distance [13]. Such findings have potential applications in relation to pulmonary rehabilitation, as well as dyspnoea-inducing activities of daily living. Other potential applications of music include being a calming distraction during unpleasant procedures; for example, music during bronchoscopy has been shown to reduce heart rate and both systolic and diastolic blood pressure [14]. Furthermore, hospital admissions are common in many chronic lung diseases, with associated psychological distress. In this setting, targeted music therapy has been shown to reduce anxiety levels and physiological correlates including blood pressure [15].

Music making

Actively making music is a further area of interest. Singing, for example, is a complex physical activity involving breath, posture and voice control, and the active use of respiratory muscles. Group singing creates a social component. Perhaps not surprisingly, there is a growing body of evidence suggesting a range of health and well-being benefits from singing in both healthy individuals and people with chronic disease [16]. A recent systematic review suggested that group singing can have a positive impact on health-related quality of life in a range of health conditions; however, it is important to note that the research included was of generally low quality with methodological limitations [17]. Singing for Lung Health is a group singing programme developed specifically for people with chronic lung disease [18]. The sessions involve physical and vocal warm-ups, breath control exercises, and group singing of songs specifically chosen to aid breath control, relaxation and a sense of well-being.

Singing for Lung Health is an ever-expanding programme. There are approximately 100 singing groups in the UK, with others in Australia, New Zealand, the USA and Uganda. The enthusiasm driving this growth is further evidenced by reports of consistent participant attendance over many years. However, funding for these groups is variable and patchy. Some groups receive funding from organisations such as the British Lung Foundation, while others are paid for by the participants or charitable donations [6].

Research on singing for people with chronic lung disease suggests a range of benefits. Most studies have focused on COPD, although a small number of studies have also been conducted in asthma and cystic fibrosis [1]. Studies in COPD have found impacts on physiological parameters including maximum expiratory pressure [19], health impairment (St George's Respiratory Questionnaire) [19, 20], the physical component of the 36-item Short-Form Health Survey (SF-36) [21, 22], and the anxiety score of the Hospital Anxiety and Depression Scale (HADS) [22]. Qualitative data consistently state that participants perceive singing to be an effective therapy to improve physical and psychological functioning, and social aspects are greatly valued [6, 18, 19, 23, 24]. Importantly, evidence suggests that the training delivered for Singing for Lung Health teachers translates into a consistent pattern of training, which is important to maintain intervention fidelity in clinical trials [6, 25].

There has also been interest in the use of wind instruments. In one study using “multimodal psycho-music therapy”, which included wind instrument playing, singing and music visualisation, reported statistically significant improvements were found in the Beck Depression Inventory, chronic respiratory questionnaire self-reported dyspnoea component, and the dyspnoea visual analogue scale [26]. Additionally, a recent pilot study investigating the effect of a 12-week harmonica programme found significant improvements in respiratory muscle function (maximum inspiratory and expiratory pressures) and 6-min walk distance in COPD patients who had completed pulmonary rehabilitation [27].

Research in other chronic lung diseases has been more limited. One study involving aboriginal Australians investigated using didgeridoo and singing lessons to improve engagement with asthma management. They found the approach was highly successful, with participants enjoying the lessons and stating that their knowledge of asthma and management strategies was greatly improved. Interestingly, they also found that in the didgeridoo group, forced expiratory volume in 1 s, forced vital capacity and peak flow all significantly improved [28]. Didgeridoo has also been shown to be an effective alternative treatment for moderate obstructive sleep apnoea [29]. Other activities showing potential include beatboxing [30] and singing [31] for people with cystic fibrosis.

Overall, the evidence base remains limited. Indeed, the most researched topic in this area, a recent Cochrane review titled “Singing for adults with COPD”, found that “There is low to very low-quality evidence that singing is safe for people with COPD and improves physical health” [32]. The review calls for more, better quality research to establish the benefits attributable to singing in COPD.

Dance

Physical activity and physical performance are important components of living well in chronic lung disease. Pulmonary rehabilitation is one of the most effective components of chronic disease management; however, access is highly variable, completion rates are often poor and benefits are often of limited duration [33]. Therefore, other forms of physical activity and exercise training should be considered to complement formal pulmonary rehabilitation.

A recent systematic review and meta-analysis found that dance interventions can be equally and occasionally more effective at improving a range of health outcomes compared with other forms of physical activity [34]. With an appreciation of the impacts seen in other groups, dance groups for people with chronic lung disease now exist. This includes South Asian dance sessions in both community and hospital settings [2], and a community dance group in North London, UK. Furthermore, interest from other people with chronic lung disease in using music and dance as adjuncts to physical activity has also been shown [3]. Other groups may well exist.

There are currently no published studies on the impact of dance in chronic lung diseases. However, studies are taking place in Canada (ClinicalTrials.gov, identifier NCT03636594) and the UK. Such approaches may also have applications in other countries. In South Africa, dance and exercise to music are being used on multidrug-resistant tuberculosis wards, with participants and staff giving very positive reports [35]. In the Kyrgyz Republic, during stakeholder engagement for the development of a pulmonary rehabilitation programme, the potential for including music and dance was highlighted as a particular area of enthusiasm and interest by both participants and staff delivering programmes [36].